ORGANIC BRAIN SYNDROME

Alyssa Reed, R1February 28, 2008

OBJECTIVES

1.Define Organic Brain Syndromes

2.Approach to Organic Brain Syndromes

3.Delirium vs Dementia

4.Dementia vs Pseudodementia

5.OBS vs Psychiatric Illnesses

DefinitionsOrganic Brain Syndrome: loosely defines a group of cognitive disorders that are secondary to CNS disease, systemic disorders, or substance-related disorders

Acute OBS: delirium

Chronic OBS: dementia

Both are a confusional state that manifest as global cognitive impairment

Definitions Global Cognitive Impairment involves all levels of higher cortical fxn

- behaviour

- emotions

- judgment

- language

- abstract thinking

- psychomotor activity

DeliriumDSM IV TR

1.Disturbance of consciousness with reduced ability to focus, sustain, or shift attention

2.Evidence from the Hx, PE, Labs that the disturbance is caused by a general medical condition, medication or other substance exposure, substance withdrawal or multiple etiologies

3.A change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not accounted for better by a pre-existing, established, or evolving dementia

4.The disturbance develops over hours to days the tends to fluctuate during the course of the day

DementiaDSM IV TR

1.Memory impairment (impaired ability to learn new info or to recall previously learned info)

2.One or more of the following cognitive disturbances• aphasia (language disturbance)• apraxia (impaired motor activity)• agnosia (failure to recognize and

identify objects)• disturbance in executive functioning

(ie. planning, organizing, sequencing, abstracting

3.the course is gradual and continuing decline

Delirium EtiologyI WATCH DEATHI: Infection

W: Withdrawal

A: Acute Metabolic

T: Trauma

C: CNS dz

H: Hypoxia/Hypercarbia

D: Deficiencies

E: Environmental/Endocrine

A: Acute Vascular

T: Toxins/Drugs

H: Heavy Metals

DDX

•INFECTIOUS- Sepsis- Encephalitis/Meningitis- CNS Abscess- Syphilis

•WITHDRAWAL- EtOH- Barbiturates- Benzos

DDX

•ACUTE METABOLIC- Acidosis- Electrolyte disturbances - Hepatic and Renal Failure

•TRAUMA- Head- Burns

DDx• CNS Dz

- Bleeds (SAH, EPH, SDH, ICH)

- CVA

- Vasculitis

- Tumor

- Increased ICP

- Seizure

• HYPOXIA

- COPD

- Pneumonia

- CO

- Methemoglobinemia

DDx•DEFICIENCIES

- B12

- Niacin

- Thiamine

• ENVIRONMENTAL

- hypothermia/hyperthermia

• ENDOCRINE

- thyroid

- adrenal

- DKA/HHS

DDx• ACUTE VASCULAR

- hypertensive encephalopathy

- intracranial bleed

- cerebral vein thrombosis

• TOXINS/DRUGS

- medications

- drugs of abuse

• HEAVY METALS

- lead

- mercury

Approach

1.Hx2.Physical Exam3.Mental status exam4.Investigations

Hx

MSE• Poorly done by ED physicians

• Usually only orientation to person, place, time

• Should include assessment of

- orientation

- memory

- attention

- concentration

- constructional tasks

- spatial discrimination

- arithmetic ability

- writing

Score<24Sensitivity 87%Specificity 82%for detecting OBS

Sensitivity of 93-100%Specificity of 90-95%

Investigations

•Standard

- CBC

- Lytes, Ca, Mg, PO4

- LFTs

- Cr, BUN

- UA

InvestigationsAs Indicated ...

- CXR

- ABG

- CT head

- LP

- Blood cultures

- Tox screen

- TSH

- RPR

- HIV

- B12

CASE• 47M brought in by EMS who were called

by the police who found him outside, agitated, confused

• PMHX: friend says he is on some anti-depressant

• VS: T= 35.1, P= 120, RR= 15, O2 91% ra

• O/E: not oriented x3, mydriasis, crackles LLL/RLL

Q: OBS? Which one?

Q: What is your approach?

DDxI WATCH DEATH

I: Infection

W: Withdrawal

A: Acute Metabolic

T: Trauma

C: CNS dz

H: Hypoxia/Hypercarbia

D: Deficiencies

E: Environmental/Endocrine

A: Acute Vascular

T: Toxins/Drugs

H: Heavy Metals

Q: Top three on your DDX for this patient?

1. Drugs 2. Environment3. Infection

Pathophysiology of Delirium

Disorder of neurotransmission in cortical and subcortical regions of brain-COMPLEX!!!

1.Neurotransmitter pathways- increase serum anticholinergic activity- decrease in acetylcholine production- increased serotonin levels

2.Deficiencies of substrates for oxidative metabolism (glucose and oxygen)

3.Increase in cytokines

4.Synthesis of false neurotransmitters

Pathophys cont...Specifically for our delirious patient:

- Tricyclics can cause delirium by causing cholinergic inhibition

- Hypothermia likely causes delirium as a result of changes in the cerebral metabolic rate• cerebral metabolism decreases by

6% for each degree celcius <36• certain enzymes cannot fxn

- Infection (sepsis) has been associated with increased serotonin levels

CASE

• 75M brought in by wife who states he woke up this morning confused and disoriented

• PMHX: palliate lung cancer, CVA in 2000, MI 2004, COPD, HTN

• Meds: metoprolol, coumadin, lasix, ramipril, spiriva, ASA, recent prednisone therapy

Q: OBS?

Q: DDX?

Q: What puts him at risk for this? (risk factors)

DDx• I WATCH DEATH

I: Infection

W: Withdrawal

A: Acute Metabolic

T: Trauma

C: CNS dz

H: Hypoxia/Hypercarbia

D: Deficiencies

E: Environmental/Endocrine

A: Acute Vascular

T: Toxins/Drugs

H: Heavy Metals

Q: Top three on your DDX for this patient?

DeliriumRISK FACTORS

- Advanced age

- Dementia or cognitive impairment

- Severe underlying medical condition (Ca, AIDS)

- Intoxication with substances

- Psychiatric Illness

- Polypharmacy

- Hospitalization

CASE

•50F presents with progressive cognitive dysfunction (reduced memory, spontaneous speech difficulties), decreased ADLs, ataxia, and urinary incontinence

•on no meds, AVSS, baseline labs WNL

•Q: OBS?

•Q: what is this triad classic of?

Dementia Etiology• Dementia may be caused by more than 50

different disease states

• Approximately 10% of dementias are reversible

Primary Degenerative:1.Alzheimer’s

2.Vascular

3.Lewy Body

4.Subcortical dementias• PSP (progressive supranuclear palsy)• Huntington’s chorea• Parkinson’s

• Frontal lobe

1. Pick’s dz

Dementia in EDGoals:

1.Differentiate delirium and dementia

2.Recognize potentially reversible causes of dementia

- NPH (progressive dementia, ataxia, urinary incontinence, average age of 60)

- Tricyclic antidepressants (anticholinergic properties)

- EtOH (not just Korsakoff’s, multiple types)

- Intracerebral mass

Dementia Workup

1.Hx, PE, MSE2.Labs• CBC, lytes, LFTs, UA, TSH, B12

3.Imaging• CXR• Head CT

4.Additional

CASE• 70F who recently lost her husband of 48

years is brought in by her daughter who has noticed for the last month that she has become unable to dress herself, and is waking up very early

• PMHx: post-partum depression, MI, NIDDM

• O/E: AVSS, flat affect, not oriented to time, unable to identify a pen

Q: Is this an organic brain syndrome? Which one?

Organic Brain Syndrome: loosely defines a group of cognitive disorders that are secondary to CNS disease, systemic disorders, or substance-related disorders

Dementia vs Pseudodementia

DEMENTIA

- Insidious onset

- no psych history

- demeanor

• unconcerned

• confabulates

• struggles at tasks

- attention impaired

- cooperative

- recent>remote memory loss

PSEUDODEMENTIA

- Subacute onset

- Psych hx

- Demeanor

• distressed

• emphasizes deficits

• limits effort

- attention preserved

- poor effort

- recent and remote memory loss

** responds to tx

CASE• 22M brought in by mom who states he

has been increasingly self isolated, suspicious and irritable. Seems to talk to people who aren’t there.

• PMHx: none

• O/E: 95 16 120/86 37.1 99% 7.1, no other findings

• MSE: oriented to person but not time or place, disorganized, tangential

• LABS: bloodwork normal, marijuana and cocaine +

• Q: Dx?

Delirium vs Pscychosis

DELIRIUM

- Acute

- AbN VS

- No psych hx

- +/- involuntary muscle activity (asterixis, tremor)

- Disoriented

- Visual, Auditory, Gustatory, Tactile, Olfactory Hallucinations

PSYCHOSIS

- Acute

- Normal VS

- Psych Hx

- No involuntary muscle activity

- May be oriented

- Auditory Hallucinations

CASE

• 82F sent in from Lodge who send a note saying she is lethargic, not coming to meals. She has no complaints.

• PMHx: vascular dementia

• O/E: 102 16 108/60 93% 36.7 7.4

• Q: Approach to the elderly patient with vague complaints?

1. Complete PE2. CBC, lytes, Cr, BUN, LFTs3. CXR, ECG4. Urine R+M